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HomeMy WebLinkAboutDeficiency Form (20) ALABAMA DEPARTMENT OF HUMAN RESOURCES CHILD CARE HEALTH& SAFETY GUIDELINES DEFICIENCY REPORT SECTION A-IDENTIFYING INFORMATION Facility Name: Type o F ity: Date Visit: Kidz Cam Day 1� Night ❑❑ /�/ �� Both ❑ month/ day / year Facility Address: 1256 HWY 43 Telephone#: Killen, AL 35645 (256) 272-5060 Ages: ! Staff in Charge(rf applicable): Capacity: f 6 wks-14 yrs / X Amanda Robertson da I / night 46 / X day / night SECTION B-DEFICIENCY INFORMATION Column 11 Column 2 Health&Safety Guidelines Date Corrected Deficiency l ) 1 VSfl 4A bra 6 INSTRUCTIONS TO PERSON IN CHARGE: Column 2, Date Corrected is to be completed by the facility representative after each deficiency is corrected The facility representative must put the orrec' and his/her initials in Column 2. This form must be returned to the Department of Human Resources on or before 1.1 Z42J as verification that deficiencies have been correcte I *Hazards must be corrected immediately I NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Health & Safe�Guidelines. A facility approved by the Department must meet Health&Health&Safe�Guidelines applicable to that facility at all times. It is the responsibility of the facility to operate in complianceth Health&Safe�Guidelines. Signature of Facility Representative Date I-JA-21 Signature of DHR Represe Date I COPIES TO:Amanda Robertson Page `of